The cardinal principle of the management of the poisoned patient is meticulous supportive care.
Gastrointestinal decontamination plays a limited role in the routine management of poisoned patients.
Ipecac-induced emesis, gastric lavage, and cathartics should not be considered in the poisoned child.
Activated charcoal or whole bowel irrigation (WBI) are potential interventions in a limited number of patients.
Antidotes are available for a limited number of poisonings.
Over the past several decades, fatalities associated with pediatric poisoning have fallen steadily, from 450 deaths in 1960 to just 50 in 2015; 42 of these were in patients 5 years old or younger.1 Interventions such as child-resistant packages, poison-education programs designed to increase household awareness of potential toxins, and improved intervention at both the poison center and hospital levels have all contributed to this decrease in pediatric mortality to just 2.3% of all poisoning deaths.1
However, pediatric exposures account for approximately 60% of all poisonings reported to the nation’s poison control centers, as noted by the most recent annual report from the American Association of Poison Control Centers.1 This report also shows that nearly half of all pediatric exposures occurred in children 5 years of age or younger. Fortunately, most of these tend to be unintentional ingestions of small doses and thus result in minimal toxicity. However, most adolescent and adult poison exposures are purposeful, involving larger doses, and thus result in greater morbidity and mortality. These intentional exposures include suicide gestures, recreational substance use, and Munchausen syndrome by proxy.2
It is often difficult to obtain an accurate history. In children who are either too young to provide specific details, or who have an altered level of consciousness from their ingestion, alternative sources of information should be considered. Essential historical points include the specific identification of the substance, when it was ingested, the amount ingested, and what other medications or poisons are available in the home. If possible, sending a family member back to the home to collect pill bottles, including over-the-counter and herbal supplements/vitamins, can be very informative. Overall, it is prudent to assume the worst-case scenario until proven otherwise.2–4
The physical examination may provide valuable information regarding the ingestion or exposure. Specific focus upon vital signs and level of consciousness is paramount in assessing the degree of toxicity. Many drugs and toxic agents have specific effects on the heart rate, respiratory rate, blood pressure, and temperature; as such, vital sign monitoring is of the utmost importance (Table 113-1). The level of consciousness, pupil size, and the presence of coma or seizures may provide clues regarding the identity of the ingested poison (Tables 113-2 and 113-3). Other diagnostic clues may be obtained from examination of the skin (Table 113-4) and breath odor (Table 113-5). Several groups of poisons present with typical patterns of signs. Recognizing these toxic syndromes (toxidromes) may expedite diagnosis and management5,6 (Tables 113-1, 113-2, 113-3, 113-4, 113-5, 113-6).
Bradycardia (PACED) Propranolol (β-blockers), poppies (opiates), propoxyphene, physostigmine Anticholinesterase drugs, antiarrhythmics Clonidine, calcium channel blockers Ethanol or other alcohols Digoxin, digitalis | Hypotension (CRASH) Clonidine, calcium channel blockers Rodenticides (containing arsenic, cyanide) Antidepressants, aminophylline, antihypertensives (β-blockers) Sedative-hypnotics Heroin or other opiates |
Tachycardia (FAST) Free base or other forms of cocaine, Freon Anticholinergics, antihistamines, antipsychotics amphetamines, alcohol withdrawal Sympathomimetics (cocaine, caffeine, amphetamines, PCP), solvent abuse, strychnine Theophylline, TCAs, thyroid hormones | Hypertension (CT SCAN) Cocaine Thyroid supplements Sympathomimetics Caffeine Anticholinergics, amphetamines Nicotine |
Hypothermia (COOLS) Carbon monoxide Opioids Oral hypoglycemics, insulin Liquor (alcohols) Sedative-hypnotics | Rapid respiration (PANT) PCP, paraquat, pneumonitis (chemical), phosgene ASA and other salicylates Nerve agents Toxin-induced metabolic acidosis |
Hyperthermia (NASA) Neuroleptic malignant syndrome, Nicotine Antihistamines, alcohol withdrawal Salicylates, sympathomimetics, serotonin syndrome Anticholinergics, antidepressants, antipsychotics | Slow respiration (SLOW) Sedative-hypnotics (barbiturates, benzos) Liquor (alcohols) Opioids Weed (marijuana) |
| Coma (Lethargic) | Seizures (Otis Campbell)a |
|---|---|
Lead, lithium Ethanol, ethylene glycol, ethchlorvynol Tricyclic antidepressants, thallium, toluene Heroin, hemlock, hepatic encephalopathy, heavy metals, hydrogen sulfide, hypoglycemics Arsenic, antidepressants, anticonvulsants, antipsychotics, antihistamines Rohypnol (sedative hypnotics), risperidone GHB Isoniazid, insulin Carbon monoxide, cyanide, clonidine | Organophosphates, oral hypoglycemics Tricyclic antidepressants, theophylline Isoniazid, insulin Sympathomimetics, strychnine, salicylates Camphor, cocaine, carbon monoxide, cyanide, chlorinated hydrocarbons Amphetamines, anticholinergics Methylxanthines (theophylline, caffeine), methanol Phencyclidine (PCP), propranolol Benzodiazepine withdrawal, botanicals (water hemlock, nicotine), bupropion, GHB Ethanol withdrawal, ethylene glycol Lithium, lidocaine Lead, lindane |
Diaphoretic Skin (SOAP) Sympathomimetics Organophosphates Acetylsalicylic acid or other salicylates Phencyclidine | Flushed or Red Appearance Anticholinergics, niacin Boric acid Carbon monoxide (rare) Cyanide (rare) |
Dry Skin Antihistamines, anticholinergics | Cyanosis Ergotamine Nitrates Nitrites Aniline dyes Phenazopyridine Dapsone Any agent causing hypoxemia, hypotension, or methemoglobinemia |
Bullae Barbiturates and other sedative-hypnotics, Bites: Snakes and spiders | Acneiform Rash Bromides Chlorinated aromatic hydrocarbons |
| Odor | Possible Source |
|---|---|
| Bitter almonds | Cyanide |
| Carrots | Cicutoxin (water hemlock) |
| Fruity | Diabetic ketoacidosis, isopropanol |
| Garlic | Organophosphates, arsenic, dimethyl sulfoxide (DMSO), selenium |
| Gasoline | Petroleum distillates |
| Mothballs | Naphthalene, camphor |
| Pears | Chloral hydrate |
| Pungent aromatic | Ethchlorvynol |
| Oil of wintergreen | Methyl salicylate |
| Rotten eggs | Sulfur dioxide, hydrogen sulfide |
| Freshly mowed hay | Phosgene |
Cholinergic Examples: organophosphates, carbamates, pilocarpine Muscarinic – Peripheral (DUMBELLS) Diarrhea, diaphoresis Urination Miosis Bradycardia, bronchosecretions Emesis Lacrimation Lethargic Salivation | Anticholinergic Examples: antihistamines, cyclic antidepressants, atropine, benztropine, phenothiazines, scopolamine Hyperthermia (HOT as a hare) Flushed (RED as a beet) Dry skin (DRY as a bone) Dilated pupils (BLIND as a bat) Delirium, hallucinations (MAD as a hatter) Tachycardia Urinary urgency and retention |
Sympathomimetic Examples: cocaine, amphetamines, ephedrine, phencyclidine, pseudoephedrine Mydriasis Tachycardia Hypertension Hyperthermia Seizures | Nicotinic – Central (days of the week) M–Mydriasis T–Tachycardia W–Weakness T–Tremors F–Fasciculations S–Seizures S–Somnolent |
Opioid Examples: heroin, morphine, codeine, methadone, fentanyl, oxycodone, hydrocodone Miosis Bradycardia Hypotension Hypoventilation Coma | Withdrawal Diarrhea Mydriasis Goose flesh Tachycardia Lacrimation Hypertension Yawning Cramps Hallucinations Seizures (with ETOH and benzodiazepine withdrawal) |
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